QUICK GUIDE:
CLINICAL INPUT
INTO CARE HOMES
England
TRANSFORMING URGENT AND EMERGENCY CARE SERVICES IN ENGLAND
This is one of a series
of quick, online guides
produced by NHS England
with partners providing
practical tips and case
studies to support health
and care systems.
Click below to view
• Better use of care at home
• Identifying local care home
placements
• Improving hospital discharge
into the care sector
• Sharing patient information
• Technology in care homes
INTRODUCTION
Residents in care homes often experience difficulties accessing the right care at the right time.
Improving the clinical input into a home and tailoring care around the diverse needs of individual
residents can improve the quality of care and quality of life for people, and reduce unnecessary
hospital admissions. It is important to bear in mind that all care homes1 and residents have specific
needs, and residential homes have distinct needs from nursing homes.
NHS England has worked collaboratively with stakeholders across different settings to develop
this Quick Guide, which comprises of case studies, ideas and practical tips on how to improve the
clinical care for people living in care homes for commissioners and providers. The contents of this
Quick Guide are to be taken as pragmatic recommendations to support local health and social care
systems; they are not mandatory; and should be read alongside the ‘Quick Guide: Identifying Local
Care Home Placements’ and the ‘Quick Guide: Technology in Care Homes’.
This Quick Guide is part of longer term work to support clinical input to care homes being led by
NHS England in partnership across the health and care system. Commissioners and providers may
also find the British Geriatric Society’s Commissioning Guide and accompanying resources of use.
HOW TO BUILD EFFECTIVE RELATIONSHIPS
Overwhelmingly, the most important tips that stakeholders have shared on improving the clinical
input into care homes are the importance of partnership working and the inclusion of care
homes in planning and decision making. Effective communication will ensure the delivery of
comprehensive patient care.
1. Local health and care systems may wish to come together to review what additional support
can be put in place in advance of this winter, using existing regulatory framework information,
needs assessment, audit of care home residents and dialogue with the care homes and residents
themselves. Some examples of approaches taken to understand care homes needs are Sutton
CCG and Nottingham City CCG, who have commissioned a ‘worry-catcher’ service from Age
UK to review resident experience on an ongoing basis;
2. Commissioners could set up care home forums to facilitate improved joint working:
- Vale of York CCG has a care home forum with the Local Authority;
- Sutton CCG has a bi-monthly care home forum and a care home buddying system;
- Frimley System Care Home Forum;
3. Health and care systems could use training delivered to care homes as an opportunity to build
stronger relationships;
4. Commissioners could make an up-to-date directory of services available to care homes, for
example Vale of York CCG has produced a directory of services specifically for care homes.
1 For the purposes of this document, we are referring to care homes as an umbrella term for both residential homes
(with no on-site nursing) and nursing homes.
2
HOW TO MAKE BEST USE OF A MULTIDISCIPLINARY TEAM (MDT)
MDTs involve a range of health and care professionals, from one or more organisations, working
together to deliver comprehensive patient care. The benefits of such an approach can include
improved health outcomes, enhanced satisfaction for residents and a more efficient use of resources.
1. MDT members could make sure that everyone has email addresses and telephone contact
details for the wider team involved in delivering care - a simple measure that has been found to
be essential for achieving outcomes;
2. MDT members could make sure that information about medical care and medication is made
available across all professionals caring for each resident, together with information about
a resident’s needs as they affect the person’s health. This should be supported by training,
supervision and role clarity. Find out more on record sharing here; and refer to the Quick Guide:
Sharing patient information;
3. MDT members could look at working flexibly - not all members need to be present for the whole
meeting - e.g. in North Staffordshire the geriatrician dials into the relevant part of meetings;
4. Commissioners and providers could review policies to check that they do not exclude care
homes for core services - often care home residents do not receive the basic NHS support they
are entitled to - see the British Geriatrics Society report Failing the Frail;
5. Commissioners could consider trying new approaches - reviewing all the time to make sure it works;
6. MDT members may find the following handbooks useful: MDT working, Personalised care and
support planning and Using case finding and risk stratification (a key service component for
personalised care and support planning).
Some examples of MDTs
Area
Reported impact
Shared management of the care and support
for care home residents between GPs and
community geriatricians.
Leicester
60% reduction in admission
costs.
GPs, pharmacist and community psychiatrist
proactively support patients through regular
visits and telephone and skype links.
North
Staffordshire
20% reduction in admissions
and significant reduction in
net mean costs per patient.
Integrated Community Ageing Team provides
specialist support for care homes and a
community geriatric service for the wider
population- monthly MDT meetings, an inreach service, weekly teleconferences and a
telephone advice line.
Islington
26% decrease in admission
and 87 less bed days
per month. Improved
communication and better
working relationships across
the community.
Three geriatricians, two advanced nurse
practitioners, a GP, a nurse case manager and
administrative support, providing services such
as risk stratification, proactive reviews, care
plans and palliative care services.
South
Manchester
26% reduction admission
and 68% reduction in
emergency bed days.
Other examples of MDT working with care homes are Birmingham East and North and South
Warwickshire.
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HOW TO ENHANCE NURSING AND THERAPIES IN CARE HOMES
The role of nurses and therapists is fundamental in the planning and managing of care for
residents with complex conditions. Such professionals often work at the interface of health and
social care, are instrumental in co-ordinating patient care pathways following discharge from
hospital, and can help to create a shift from reactive care to more proactive models of care,
based on early intervention.
1. Care homes may wish to encourage all staff and residents to have a flu vaccination;
2. Care homes could consider using the College of Occupational Therapy’s Living Well Through
Activity in Care Homes guides;
3. Commissioners and local NHS Trusts could consider introducing dedicated nursing support to
care homes, for example:
- Cornwall has introduced a virtual care home team, made up of a nurse practitioner for care
homes and a dementia liaison nurse, and has introduced a whole suite of care home specific
clinical management tools, including falls prevention, UTIs, delirium and Parkinsons;
- Heart of Birmingham employs a nurse prescriber as a case manager to local care homes they act as the first point of contact for care home queries, providing short term interventions
and coordinating care. This has seen reductions in emergency admissions by 25%;
- Worcestershire achieved a 23.1% reduction in A&E attendances through assigning a
community nurse practitioner to specific care homes;
- The East Sussex nurse-led rapid intervention in care homes (ENRICH) service works with care
homes to improve clinical decision making to reduce avoidable admissions;
- South Tyneside NHS Foundation Trust has established a round the clock Gateshead Urgent
Care Team providing urgent, nurse-led care to care homes;
4. Commissioners could streamline pathways of care, for example:
- N&E Hertfordshire has introduced a single intermediate care pathway;
- London Ambulance Service has developed a falls pathway for residents in care homes;
- Hampshire has introduced a county-wide post falls protocol;
5. Commissioners could ensure that care plans have been put in place for every new resident
to care homes by community matrons, for example in Ashford CCG and Canterbury and
Coastal CCG.
HOW TO IMPROVE GENERAL PRACTICE INPUT
TO CARE HOMES?
With multiple co-morbidities and multiple medication use, residents in care homes are often the
most medically complex people in the community. According to figures from the British Geriatrics
Society, 68% of care home residents have no regular medical review, 44% have no regular review
of medications and just 3% have occupational therapy - a critical service to promote independence.
Residents need structured and pro-active approaches to their care, with coordinated teams working
together built on primary care.
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1. Commissioners could determine what constitutes an enhanced general practice service
over and above the core service that is already commissioned for every resident - for example
North Staffordshire used the funding formula £100 per new patient comprehensive geriatric
assessment, plus £175 per resident per year, and introduced a Locally Enhanced Service that
includes payment for new patient reviews, a review of people whose condition has changed
significantly and post discharge visits;
2. Commissioners and GP practices could ensure that care home residents are receiving
proactive support (such as visits for comprehensive assessment and care planning) - for example
the Care Home Assessment and Review Service pilot by Wirral CCG;
3. Commissioners and GP practices could consider allocating one GP to each care home to
provide consistency in care to residents and greater care planning, for example in Sheffield this
achieved a 9% reduction in admissions;
4. Commissioners and GP practices could consider delivering clinics within care homes,
for an example see Suffolk.
HOW TO MANAGE MEDICINES IN CARE HOMES
Residents in care homes are among the most vulnerable members of our society, reliant on care
home staff for many of their everyday needs. A combination of complex medical conditions may
lead to the need to take multiple medications, with care home residents taking 7-8 medications
on average.
1. Commissioners and MDTs could ensure thorough medication reviews of care home residents
occur on a regular basis. For example:
- NHS Aylesbury Vale and Chiltern CCG;
- Shine Project in North Tyneside;
- Sandwell and West Birmingham Hospitals have reported medication savings by implementing
a Care Home Review team consisting of a consultant geriatrician, a nurse and a pharmacist;
- Cumbria’s STOPP / START tool;
- Reviewing the use of antipsychotic drugs;
2. Care homes and MDTs could consider how they manage care home residents’ medicines,
for example:
- Torbay has developed a medicines management checklist tool;
- Sheffield has commissioned specific community pharmacy advice for care homes;
- Use of National Care Forum resources within care homes on safe use of medicines;
3. Commissioners and care homes could consider schemes to ensure accurate information
is available on patients’ medications on admission and discharge from hospital, for example
South Central’s green bag scheme;
4. Care homes could introduce calcium and vitamin D supplements for residents,
where clinically appropriate.
5. Care homes and MDTs can arrange for community pharmacies to provide flu vaccination
services within care homes. Details can be found here.
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HOW TO SUPPORT PEOPLE WITH DEMENTIA IN CARE HOMES
More than 80% of people living in care homes have a form of dementia or severe memory problems.
According to research by the Alzheimer’s Society, many people with dementia are not receiving the
level of person-centred care they need.
1. Commissioners could put in place measures for improved diagnosis and screening of people
with dementia within care homes. For example:
- Bexley GPs have reviewed all care home residents to diagnose people with dementia;
- In Yorkshire, Dementia Forward has been commissioned to liaise between care home
managers and GPs to support dementia diagnosis and screening;
2. Commissioners could consider providing specific support to nursing home staff on dementia.
For example:
- Suffolk has introduced a non-specialist dementia advice phone line which is reducing
unnecessary admissions;
- Sussex Partnership Trust has been commissioned by Surrey CCGs to provide a dementia
in-reach service to care homes to reduce the use of antipsychotic drugs through nonpharmacological interventions - slowing down escalation to higher levels of care, improving
quality of life of residents and reducing avoidable admissions;
- Nottingham City CCG commissions a specialist Dementia Outreach Team, which offers
specialist support and training to care homes that have residents with dementia;
- The Centre for Assisted Technology and Connected Healthcare has considered which
technologies could help people with dementia within care home settings.
HOW TO IMPROVE ORAL HEALTH, HYDRATION AND
NUTRITION IN CARE HOMES
Residents in care homes need to maintain good oral health, and access to nutritious food and drinks.
1. Care homes and commissioners could consider what they can introduce to improve hydration
and nutrition. For example:
- In Peterborough, a review of residents in care homes using the Malnutrition Universal
Screening Tool resulted in a 27% reduction in hospital admissions and 58% reduction in the
length of any hospital stays of residents;
- Birmingham Council has developed a urine analysis tool that can be used easily by care home staff
to check for dehydration in residents, particularly those with dementia who are more prone;
2. Care homes could consider what they can introduce to improve the oral health of residents:
- Ensuring that residents have access to oral hygiene products such as toothbrush and fluoride
toothpaste, and denture cleaning items;
- Supporting residents’ tooth brushing regularly. This can be done using a simple chart at the
bed or chair side;
- Supporting residents with looking after dentures;
- Access to appropriate dental treatment when required and the name of their dental practice
should be noted.
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HOW TO IMPROVE END OF LIFE CARE IN CARE HOMES
The median period from admission to the care home to death is 15 months, thus end of life care
must be at the heart of an integrated approach to care and support for residents. The Ambitions
for Palliative and End of Life Care: A national framework for local action 2015-2020 contains 6
ambitions, along with building blocks to help make person centred end of life care a reality.
1. Local health and care systems could consider introducing initiatives which will support
improved end of life care, for example:
- Nottinghamshire has introduced Electronic Palliative Care Systems (EPaCCs);
- Leicester City CCG is using the ‘Deciding Right’ - planning your care in advance initiative
to support advance care planning;
- ‘Share my care’ is an example of an electronic system used by Ashford CCG and
Canterbury and Coastal CCG care homes to share residents’ care plans and wishes.
HOW TO HARNESS TECHNOLOGY IN CARE HOMES
Technology presents an opportunity to enhance the quality of care for residents and can improve
operational efficiencies; reduce risks/errors; increase capacity to manage limited resources effectively
and most importantly, give health and care staff more time to deliver personalised care and support.
Training and confidence in the technology being used is essential so that care home staff value the
system and use it.
Local health and care systems could consider where technology could be introduced and carry
out a costs benefits analysis of new systems. Please refer to the Quick Guide: Technology in Care
Homes for examples of how technology is being used.
HOW TO PROMOTE MENTAL HEALTH AND
WELLBEING IN CARE HOMES
We know that physical activity and access to essential healthcare services are very important in the
support of people’s mental wellbeing. Empowering older people in care homes to be involved in all
decisions about their lifestyle and care is fundamental to their mental wellbeing.
Care homes could consider what they can put in place to support their resident’s mental health
and wellbeing, with some examples and useful guides below:
1. Use care homes as a community hub, particularly in rural areas;
2. Use tools to identify deterioration in wellbeing and mental state;
3. Various care homes have introduced iPads for residents to use;
4. The Relatives and Residents Association has developed a number of products that can be used
to promote health and wellbeing within care home;
5. The National Council for Voluntary Organisations is running a Volunteering in Care Homes
project, developing standards for volunteering within this specific environment.
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HOW TO SUPPORT AND UPSKILL CARE HOME STAFF
The majority of care homes residents are living with complex co-morbidities. As those residents age,
their health needs inevitably increase. Upskilling and providing ongoing support for staff in clinical care
can lead to a reduction in avoidable admissions and improve the quality of care provided to residents.
1. Local health and care systems could include care homes in any training offers as a key
partner in the system, for example the training for people with frailty to support self-care
provided across Nottinghamshire, and could consider delivering bespoke training to care home
staff on some of the topics listed below, alongside ongoing support and advice. Any training
offers should take into account the difficulties for care home staff to attend training and so a
combination of e-learning and in-house training would work best;
2. Commissioners may wish to identify the highest admitting care homes and provide tailored
training and education for staff, for example North West Surrey CCG;
3. Commissioners may wish to consider putting in place protocols for ‘health delegated tasks’
to social care, for example Leicester, Leicestershire and Rutland has developed a protocol and
training passport.
Type of training
Examples of where this has been
delivered to care homes
Tissue viability
(pressure ulcers and wound care)
National campaign Your Turn;
Sussex Community NHS Trust; React to Red
Skin campaign by Coventry and Rugby CCG.
Patient Group Directions (PGDs) for UTIs, chest
infections, IV, catheters
Gateshead urgent care team;
Sussex Community NHS Trust.
Dementia
North Central and North East London;
York and Humber; Brighton and Hove CCG;
Four Seasons PEARL project.
Falls prevention
University Hospitals Birmingham NHS
Foundation Trust.
Nutrition and hydration
Sussex Community NHS Trust;
North East Hampshire and Farnham CCG.
Medicines management
North West Surrey CCG.
End of life care and advance care planning
‘Circle of Life’ Board Game; St Christopher’s
Hospice ‘6 Steps to Success’; Gold Standards
Framework care home training.
Improving oral care
Health Education England in Kent Surrey
and Sussex.
Frailty
Derbyshire and Nottinghamshire.
Leadership training for care home managers
My Home Life Transformation Package.
Care Certificate
Standards for non-regulated health and
social workers.
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Please sign up to the newly established Care Home Network
on the Better Care Exchange to get involved in the next steps.
Special thanks goes to these organisations for their support, time, effort and commitment
during the development of this Quick Guide.
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NHS England Publications Gateway Reference 04251